Opinion
For Taurino Reyes, Plaintiff: Denise Bourgeois Haley, LEAD ATTORNEY, Lawrence D Rohlfing Law Offices, Santa Fe Springs, CA.
For Carolyn W Colvin, Acting Commissioner of Social Security, Defendant: Assistant U.S. Attorney LA-CV, LEAD ATTORNEY, AUSA - Office of U.S. Attorney, Civil Division, Los Angeles, CA; Assistant U.S. Attorney LA-SSA, LEAD ATTORNEY, Office of the General Counsel for Social Security Adm., San Francisco, CA; Francesco P Benavides, LEAD ATTORNEY, SAUSA - U.S. Attorney's Office, Social Security Administration, San Francisco, CA.
ORDER REVERSING DECISION OF COMMISSIONER AND REMANDING FOR FURTHER ADMINISTRATIVE PROCEEDINGS
DAVID T. BRISTOW, UNITED STATES MAGISTRATE JUDGE.
Plaintiff filed a Complaint (" Complaint") on August 7, 2014, seeking review of the Commissioner's denial of his applications for Disability Insurance Benefits and Supplemental Security Income. In accordance with the Magistrate Judge's Case Management Order, the parties filed a Joint Stipulation (" Jt. Stip.") on May 22, 2015. Thus, this matter now is ready for decision.
As the parties were advised in the Case Management Order, the decision in this case is being made on the basis of the pleadings, the Administrative Record (" AR"), and the Joint Stipulation filed by the parties. In accordance with Rule 12(c) of the Federal Rules of Civil Procedure, the Court has determined which party is entitled to judgment under the standards set forth in 42 U.S.C. § 405(g).
DISPUTED ISSUE
Whether the Administrative Law Judge (" ALJ") properly evaluated the opinion of examining psychologist Christopher Michael, Ph.D. (" Dr. Michael") and supporting medical evidence of plaintiff's mental limitations. (Jt. Stip. 4-27.)
DISCUSSION
I. The ALJ failed to properly evaluate the medical evidence .
In Disputed Issue One, plaintiff contends that he " takes issue with the ALJ's consideration and rejection of the examining opinion of the agency's own physician Dr. Michael as well as supporting opinion and record of treating [psychiatrist Hassan Mahfoozi, M.D. (" Dr. Mahfoozi")]." (Jt. Stip. 8.) Specifically, plaintiff asserts the ALJ erred because his " residual functional capacity [(" RFC")] does not include any limitation on the ability to relate to supervisors or coworkers or serious impairment in the ability to withstand the stress and change in an average 8 hour work day." (Id.) Plaintiff asserts that the " ALJ failed to articulate a legally sufficient rationale to reject the ignored portions of those opinions." (Id.)
In evaluating medical opinions, the Ninth Circuit distinguishes among three types of physicians: (1) Treating physicians (who examine and treat), (2) examining physicians (who examine but do not treat), and (3) non-examining physicians (who neither examine nor treat). Lester v. Chater, 81 F.3d 821, 830 (9th Cir. 1996) (as amended). In general, more weight should be given to the opinion of a treating physician than to a non-treating physician, and more weight to the opinion of an examining physician than to a non-examining physician. Id. Although a treating physician's opinion is entitled to special weight, McAllister v. Sullivan, 888 F.2d 599, 602 (9th Cir. 1989) (as amended), " [t]he treating physician's opinion is not, however, necessarily conclusive as to either a physical condition or the ultimate issue of disability." Magallanes v. Bowen, 881 F.2d 747, 751 (9th Cir. 1989). The weight given to a treating physician's opinion depends on whether it is supported by sufficient medical data and is consistent with other evidence in the record. See 20 C.F.R. § § 404.1527(d)(2) and 416.927(d)(2). When a treating or examining physician's opinion is not contradicted by another physician, it may only be rejected for " clear and convincing" reasons. Lester, 81 F.3d at 830. Where the treating or examining physician's opinion is contradicted, it may not be rejected without " specific and legitimate reasons" supported by substantial evidence in the record. Id. at 830-31; see also Carmickle v. Comm'r, Soc. Sec. Admin., 533 F.3d 1155, 1164 (9th Cir. 2008).
On September 30, 2011, Dr. Michael performed a complete psychological evaluation of plaintiff. (AR 408-14.) After a limited review of the records, a psychological evaluation, a mental status examination, a clinical interview, and administering a Wechsler Adult Intelligence Scale -- 4th edition, Wechsler Memory Scale -- 4th edition, Trail Making Test, Parts A and B, and Rey 15-Item Memory Test, Dr. Michael diagnosed plaintiff with major depressive disorder, severe, with psychotic features. (AR 408, AR 413.) Dr. Michael assessed a Global Assessment of Functioning (" GAF") score of 40. Dr. Michael opined that plaintiff " would have mild impairment in understanding, remembering, and carrying out short, simple instructions, " moderate impairment in his " ability to understand, remember, and carry out detailed instructions, and mild impairment in his " ability to make judgments on simple, work-related decisions." (AR 414.) Dr. Michael also determined that " [p]er [plaintiff's] presentation in the assessment session and self-report, [he] is likely to experience significant difficulties in relating appropriately to the public, supervisors, and co-workers" and his " ability to withstand the stress and changes associated with an 8-hour workday and day-to-day work activities is likely seriously impaired." (AR 414.)
A GAF score is the clinician's judgment of the individual's overall level of functioning. It is rated with respect only to psychological, social, and occupational functioning, without regard to impairments in functioning due to physical or environmental limitations. See American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders (" DSM-IV") 32 (4th ed. 2000).
On July 10, 2011, Dr. Mahfoozi completed a Mental Disorder Questionnaire form on behalf of plaintiff. (AR 403-07.) Dr. Mahfoozi reported he began treating plaintiff on December 8, 2009. (AR 407.) In the form, Dr. Mahfoozi stated plaintiff " is socially isolated" and opined plaintiff is " unable to work" and " adapt to stresses common to the work environment." (AR 406.) Dr. Mahfoozi diagnosed plaintiff with major depression with psychotic features and indicated plaintiff has a " history of hospitalizations for depression." (AR 403, AR 497.)
In assessing the medical evidence with respect to plaintiff's mental impairments, the ALJ assigned " partial weight" to Dr. Michael's opinion and " little weight" to Dr. Mahfoozi's opinion. (AR 33.) The Court concludes the ALJ properly assessed Dr. Michael's opinion, but failed to provide legally sufficient reasons for rejecting Dr. Mahfoozi's opinion.
Here, the ALJ partially rejected Dr. Michael's opinion because " his low GAF score is inconsistent with his [RFC] determination that [plaintiff] was only moderately limited in his concentration, persistence and pace as well as social functioning while being able to perform simple tasks." (AR 33); see Batson v. Comm'r of Soc. Sec., 359 F.3d 1190, 1195 (9th Cir. 2004) (ALJ may discredit treating physicians' opinions that are conclusory, brief, and unsupported by the record as a whole, or by objective medical findings); 20 CFR § § 404.1527(c)(4), 416.927(c)(4) (" Generally, the more consistent an opinion is with the record as a whole, the more weight we will give to that opinion."). Dr. Michael assessed a GAF score of 40, which indicates " [s]ome impairment in reality testing or communication (e.g. speech is at times illogical, obscure, or irrelevant) [or] major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood (e.g. depressed man avoids friends, neglects family, and is unable to work; child frequently beats up younger children, is defiant at home, and is failing at school)." DSM-IV at 34 (emphasis omitted). The Court agrees that a GAF score of 40 is at odds with Dr. Michael's finding that plaintiff's ability to understand, remember, and carry out short, simple instructions is mildly impaired and his " ability to understand, remember, and carry out detailed instructions is moderately impaired." (AR 414.)
Indeed, although Dr. Michael also found plaintiff " is likely to experience significant difficulties in relating appropriately to the public, supervisors, and co-workers, " Dr. Michael noted that these limitations were based on plaintiff's presentation in the " assessment session, " which Dr. Michael described as " somewhat problematic." (AR 409, AR 414.) Dr. Michael reported that the results of the psychological testing administered " should be interpreted with significant caution" and " not as fully valid." (AR 411.) Further, with respect to the mental status examination, Dr. Michael determined that plaintiff's " [t]est-taking effort was either poor or his performance was negatively impacted by emotional factors." (AR 410.) Accordingly, the ALJ did not err in giving partial weight to the RFC determination assessed by Dr. Michael.
Plaintiff argues that Dr. Michael's opinion is supported by treating psychiatrist Dr. Mahfoozi's opinion, which the ALJ failed to properly assess. (See Jt. Stip. 8, Jt. Stip. 12-14.) The Court agrees the ALJ did not provide legally sufficient reasons for rejecting Dr. Mahfoozi's opinion. The ALJ assigned little weight to Dr. Mahfoozi's opinion because it was not supported by the psychiatrist's own notes or the record as a whole. (See AR 33 (ALJ rejecting Dr. Mahfoozi's opinion because it is " internally inconsistent and not consistent with the medi[c]al evidence").) However, this reasoning is not supported by substantial evidence. For example, Dr. Mahfoozi opined that plaintiff would be unable to " adapt to stresses common to the work environment." (AR 406.) The treatment notes support this conclusion. Specifically, a review of the record reveals that plaintiff suffers from auditory hallucinations, paranoid delusions, and frequent anxiety attacks. (See, e.g., AR 548 (treatment note, dated February 14, 2012, indicating plaintiff is not oriented to person and place, thought processes are marked with flights of ideas, and is suffering from paranoid delusion), AR 552 (treatment note, dated September 24, 2011, indicating plaintiff is " still paranoid, " his thought processes are marked with " blocking"), AR 553 (treatment note, dated August 20, 2011, indicating plaintiff is " still hearing 'voices, '" he is suffering from auditory hallucinations and paranoid delusion, and is not oriented to place), AR 645 (treatment note, dated April 16, 2011, indicating plaintiff is suffering from paranoid delusion and auditory hallucinations), AR 660 (treatment note, dated January 23, 2013, indicating plaintiff is suffering from panic attacks two to three times per week).)
Plaintiff also contends that the ALJ mischaracterized " Dr. Mahfoozi's treatment notes as lasting only 15-30 minutes for medication analysis and not counseling." (Jt. Stip. 15.) However, this description is based on plaintiff's own testimony and Dr. Mahfoozi's notations in the treatment record. (See AR 48 (plaintiff testifying that Dr. Mahfoozi is only providing treatment with respect to " medication" and not " anything else" and has not recommended a counselor); see, e.g., AR 635 (Dr. Mahfoozi indicating his proposed treatment includes psychiatric evaluation consisting of " 15 minutes session(s)").)
Moreover, the ALJ adopted the opinion of nonexamining physician P.M. Balson, M.D. (" Dr. Balson") in formulating plaintiff's mental RFC. (See AR 33 (ALJ assigning " great weight" to Dr. Balson's opinion).) On October 12, 2011, Dr. Balson completed a mental RFC form. (AR 432-34.) Dr. Balson opined that plaintiff would be moderately limited in his ability to accept instructions and respond appropriately to criticism from supervisors, and in his ability to get along with coworkers or peers without distracting them or exhibiting behavioral extremes. (AR 433.) The ALJ failed to include this limitation in his RFC determination. (See AR 29 (ALJ limiting plaintiff to " unskilled work in a non-public work setting").) Accordingly, the ALJ's mental RFC determination is not supported by substantial evidence.
Thus, Disputed Issue One warrants reversal of the Commissioner's decision.
CONCLUSION AND ORDER
The law is well established that the decision whether to remand for further proceedings or simply to award benefits is within the discretion of the Court. See, e.g., Salvador v. Sullivan, 917 F.2d 13, 15 (9th Cir. 1990); McAllister, 888 F.2d at 603; Lewin v. Schweiker, 654 F.2d 631, 635 (9th Cir. 1981). Remand is warranted where additional administrative proceedings could remedy defects in the decision. See, e.g., Kail v. Heckler, 722 F.2d 1496, 1497 (9th Cir. 1984); Lewin, 654 F.2d at 635. Remand for the payment of benefits is appropriate where no useful purpose would be served by further administrative proceedings, Benecke v. Barnhart, 379 F.3d 587, 593 (9th Cir. 2004); where the record has been fully developed, Hoffman v. Heckler, 785 F.2d 1423, 1425 (9th Cir. 1986); or where remand would unnecessarily delay the receipt of benefits, Bilby v. Schweiker, 762 F.2d 716, 719 (9th Cir. 1985) (per curiam) (as amended).
This is not an instance where no useful purpose would be served by further administrative proceedings. Rather, this is an instance where additional administrative proceedings could remedy the defects in the ALJ's decision.
Pursuant to sentence four of 42 U.S.C. § 405(g), IT THEREFORE IS ORDERED that Judgment be entered reversing the decision of the Commissioner of Social Security and remanding this matter for further administrative proceedings.
JUDGMENT
In accordance with the Order Reversing Decision of Commissioner and Remanding for Further Administrative Proceedings, filed herewith, IT IS HEREBY ADJUDGED that the decision of the Commissioner of Social Security is reversed and this matter is remanded for further administrative proceedings.